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An audit of diabetic patients suffering from ischaemic heart disease in a primary care setting

Ivo Dukic Introduction

A clinical audit is a quality improvement process that seeks to improve patient care and outcome through systematic review of care against explicit criteria and the implementation of change1. In this audit only people who have diagnosed diabetes mellitus (DM) and ischaemic heart disease (IHD) are considered. Diabetes mellitus is a disease characterized by excess glucose in the blood due to a deficiency in insulin production or utilization. IHD refers to the spectrum of diseases where there is a lack of oxygenation of heart muscle. IHD is the major cause of morbidity and mortality in people with diabetes. Prevention of acute events and long term complications of IHD is extremely important in people with diabetes mellitus as they are already at an increased risk of developing macrovascular and microvascular diseases. The primary care provider for this audit is the Kingsway Group Practice, Manchester, United Kingdom. Objectives

The aim of the audit is to identify areas of care that need improving and to where possible to recommend changes; specifically I will be looking to:
• assess adequacy of blood pressure measurement
• assess monitoring of the body mass index (BMI) of the population
of patients who have good blood glucose control and
• evaluate smoking cessation activities
• assess blood lipid control and management and adequacy of recording
Methodology

This is a retrospective clinical audit which looks at the care provided for diabetic patients suffering from ischaemic heart disease. The Kingsway Group Practice consists of 3 full-time general practitioners who provide care for 5646 patients. All patients with diabetes mellitus (type 1 and type 2) and ischaemic heart disease were selected using Read codes, C2 and G4, respectively. Patients who had recently died were excluded from the list. A list of patients with diabetes mellitus was then cross-referenced with a list of patients with ischaemic heart disease. Data was collected using the information available on the computer register of patients. The computer system being used to get information for this audit was Torex’s System 5. I decided to record a number of variables for each patient:
• latest systolic and diastolic blood pressures
• amount of time since the last blood pressure measurement
• amount of time since last HbA1c measurement
• whether a smoking history had been recorded
• latest total blood cholesterol levels
• whether blood cholesterol levels had been measured in the last 12
• whether they had been prescribed lipid lowering agents
This audit is limited by the fact that I am only considering data on the computer records for each patient. This may mean that it does not give a fair picture of the overall care for each patient but reflects the information that is stored and audited on the computer system. Ethical issues

According to the Caldicott committee report, consent for collection of data is not required where the information has been effectively anonymised2. During data collection the data was pseudoanonymised and when recorded the data was anonymised. Results

Total number of patients in the practice
Number of patients with DM (type 1 and 2)
Number of patients with DM (type 1 and 2) and IHD
From this data prevalence of the diseases can be calculated: Prevalence of DM (type 1 and 2) 3.06
Prevalence of DM (type 1 and 2) and IHD

Percentage of patients who have DM and also suffer from IHD 24.3%Age

Age is a risk factor for the development of DM and IHD. So it is not surprising that the average age of patients in this audit was 69 years. Age is of relevance in this audit due to there only being evidence for pharmacological intervention as secondary prevention in people aged up to 75 years. Of the 42 patients in this audit 33% were above 75 years of age. Male to Female ratio and type of diabetes

There were 27 males and 15 females suffering from DM and IHD. This suggests that twice as many males are affected as females. Only 1 patient out of the 42 had type 1 diabetes mellitus and IHD. This is well below the usual distribution of diabetic disease (10% of DM are type I). Body Mass Index (BMI)

The average BMI of the DM and IHD patients was 29.9 kg/m2. This suggests that as a group, patients with DM and IHD are overweight. 13% patients had a BMI below 25. 45% had a BMI between 25 and 30. 42% had a BMI above 30. So 87% of people with DM and IHD are either overweight or obese. It is important to record BMI and creatinine levels if metformin is being prescribed due to potential side effects of the drug. If a person with diabetes is overweight they should be encouraged to lose weight and increase physical activity as this helps control diabetes and reduce symptoms of IHD. Studies have shown that it is unrealistic to expect patients to be their ideal weight but losing 5-10% of body weight in obese patients has positive effects on control of DM and IHD3. BMI recording

Significantly 26% of patients did not have a recorded BMI, height or weight on the computer system. Another problem with BMI recording was that it was not regularly followed up, or the data for BMIs was not inputted into the computer system. Usually there was only one entry of BMI, usually when the diagnosis of diabetes was made. None of the patients in this audit had records where there was regular, year on year, BMI monitoring. Blood pressure

3 (7%) patients had no recorded blood pressure on the computer system. 62% of patients had a systolic blood pressure above the suggested figure in the guidelines (≥140 mmHg)4. 46% patients had a diastolic pressure above the suggested figure in the guidelines (≥80 mmHg)4. This means that the majority of patients had a blood pressure that was above the recommended level. Hypertension increases the risk of developing macrovascular and microvascular complications5. As these patients are already at high risk of developing further complications I think it is important that their blood pressure is controlled effectively. However, good blood pressure control is difficult to achieve and complicated by side effects such as postural hypotension, especially in the elderly population. This audit is limited because it does not look at several blood pressure readings over a period of time but concentrates on analysis using only one blood pressure reading. However, the audit does suggest that blood pressure control might be an area to be audited more carefully in the near future. Blood pressure monitoring

Blood pressure should be monitored at least annually4. If blood pressure is above 140/80 blood pressure should be measured at least every 6 months4. Overall the practice performed reasonably well with 74% of patients having had their blood pressure recorded on the computer system in the last year. In the group with blood pressure 140/80 or above 43% patients had their blood pressure recorded in the last 6 months. 19% of these patients had not had their blood pressure recorded in more than 12 months. This practice operates a policy where blood pressure records are entered annually which explains the above results. HbA1c

Hameoglobin A1c is a measure of the HbA1c Levels in DM and IHD patients
nonenzymatic glycosylation of haemoglobin A in the blood stream. It is
in the blood stream. I recorded the latest
as well as the data of the sample. In this
HbA1c Levels
In the UKPDS trial6, patients with type 2 diabetes were studied for up to 15 years. Those in the lower rates of glycaemia have a significantly lower rate of developing complications. The rate of increase of risk of complications for microvascular disease with hyperglycaemia is greater than that for macrovascular disease.
In this audit 80% of patients had HbA1c levels below 7.5% suggesting good glucose control. The 20% of patients in whom blood glucose control was poor should be encouraged to monitor diet, increase exercise and lose weight. In addition, doctors should think about increasing medication for this group so as to prevent further complications. HbA1c measurement

According to the computer records, 81% of patients had their HbA1c checked within last 12 months and overall 60% of patients had their HbA1c checked within the last 6 months. 19% had not had it checked in more than 12 months and of these patients one person last had their HbA1c checked 8 years ago. According to guidelines7, HbA1c levels should be checked at 2 to 6 monthly intervals. The interval should be dependant on:
• stability of blood glucose control and / or
• change in levels of blood glucose and or
At this time, HbA1c levels are recorded on the computer register at 6 monthly intervals for 60% of the practices DM and IHD patients. It is likely that HbA1c levels are being recorded more frequently than this although this would have to be verified using each patient’s written notes. Smoking

Patients should be encouraged to stop smoking since it is a major modifiable risk factor for future development of acute ischaemic events. 79% of patients had a recorded smoking history and of these 85% did not smoke. The audit showed that 15% of DM and IHD continue to smoke. This group should be encouraged to stop completely. Significantly, 21% did not have a smoking history recorded on the computer system. It is likely that this each patients smoking history is recorded in the patients written notes but this has not been transferred yet to the computer register. Total blood cholesterol levels

When type 2 diabetes mellitus is diagnosed total cholesterol (TC), low density lipoprotein (LDL-C), high density lipoprotein (HDL-C) and triglycerides (TG) should be measured. This should be a fasting measurement. The only values recorded on the computer system were those of total cholesterol. Levels of triglycerides and low density lipoprotein were not stored on the computer. People with a normal lipid profile have TC <5.0 mmol/L (LDL-C <3.0 mmol/L) and TG less than 2.3 mmol/L. In the audit patients had an average lipid control of 4.48 mmol/L (Range of 2.8-8.0). 74% had a TC level below 5.0 mmol/L. 21% of patients were still poorly controlled and had a TC level ≥ 5.0 mmol/L. For this 21% who are still poorly controlled:
• Glycaemic control should be optimized4
• Intensive advice on diet, weight loss (in those with BMIs over 25) and physical activity
• Medication should be reviewed and if possible dosage increased4
60% patients with DM and IHD are taking some form of lipid lowering agents (fibrates or statins). 92% of these patients are using statins and 8% are using fibrates. Of the 40% who are not taking the medication 59% (10 patients) are over the age of 75. Guidelines4 on the management of type 2 diabetics recommend that all people irrespective of age should be using lipid lowering agents if they have manifest IHD. However, the research for pharmacological intervention as secondary prevention only validated the use lipid lowering agents up to 75 years4.
Whether 40% of this population is choosing not to take lipid lowering agents or whether they developed adverse reactions to the medication is not recorded. The guideline stating that all diabetic patients with manifest IHD should be using lipid lowering agents is relatively new so not all patients with DM and IHD will have been reviewed. There should be a much higher use of lipid lowering agents especially in a group with manifest IHD as this group is already at high risk of further acute ischaemic episodes. Blood lipid measurement

Blood lipid measurement should be measured annually in diabetic patients with ischaemic heart disease4. 88% of patients had a total blood lipid measurement in the last 12 months. This is a high percentage of people and suggests that the practice is monitoring blood lipid levels effectively. Problems with data recording

I am unsure as to whether all DM and IHD patients are recorded on the computer system. To assess this properly I would have to review the cases of all the patients within the practice and compare the numbers of recorded patients. In larger studies of this type it appears that not all patients who would have diabetes and ischaemic heart disease would have been entered on a computer system8. This practice is not using a paperless computer register system so the likelihood that there would be patients who are not recorded as having DM and IHD is probably increased. Summary and recommendations

Blood pressure control and a possible increase in the use of Key points
pressure should be looked at • IHD is the major cause of morbidity and
mortality for diabetic patients (type 1 and type
the small minority where HbA1c • More aggressive control of blood glucose levels
The number of patients who are smoking in this
lowering medication should be • The number of patients who are on lipid increased since all patients in this
group fit the current criteria for • Recording of data on the computer register of taking lipid lowering medication.
There should be an annual record of BMI or the patient’s weight on the computer records. Overall the practice under-records diabetic and ischaemic heart disease data on the current computer system. Important areas that should be documented on a register like this are not always present. Examples of such areas include whether:
• creatinine levels were checked annually, especially in people prescribed ACE
• any dietary advice was given to the patient
• levels of LDL-C and TG were checked, and the levels of LDL-C and TG, although this
may only be necessary when initially deciding upon a specific lipid lowering agent
• the patient has been offered medication
Improved recording of such data on the computer register would enable easier monitoring of patient care throughout the practice.
References

South East London Exceptional Treatments Commissioning Issued: March 2009 Issue No: 2 BPCT Document No: POL CM002 This Policy has been produced by the South East London Exceptional Treatments Strategy and Policy Group. Contact [email protected] for updates or copies. South East London Exceptional Treatments Commissioning (ETC) Policy Excepti